The Risk of Kidney Injury in Patients With Sickle Cell Disease Treated With Ketorolac for Acute Pain

Ketorolac, a nonsteroidal anti-inflammatory drug, is used in combination with opioids to manage vaso-occlusive episodes (VOEs). The relationship between ketorolac use and kidney injury in pediatric patients with sickle cell disease (SCD) remains incompletely understood. We hypothesize that ketorolac is associated with acute kidney injury (AKI) in patients with SCD presenting with pain. All nonsurgical hospitalizations for VOEs treated with ketorolac between January 2014 and December 2022 were included. We used optimal matching methodology to identify control admissions (2:1 ratio) and used nonparametric tests to compare ketorolac administration between cases and controls. A total of 1319 encounters/253 patients were included in this study. AKI was noted in 1.1% of encounters and 5.5% of patients. Cases had significantly higher initial BUN than controls (9.0 vs. 6.0 mg/dL, P=0.012). In cases versus controls, there was significantly lower serum sodium (136.0 vs. 138.0 mmol/L, P=0.021). There was no association between ketorolac dose and development of AKI among children with SCD. Higher BUN and lower sodium in cases suggest that patients with AKI were more volume depleted on admission than controls. This highlights the need for strict assessment of fluid status upon admission for VOE.

Sarcopenic obesity and reduced BMD in young men living with HIV: body composition and sex steroids interplay

PURPOSE

Sex steroids play a key role on male bone homeostasis and body composition (BC), their role in men living with HIV (MLWH) is less recognized. This study aimed at investigating the prevalence of low BMD, sarcopenia, and sarcopenic obesity (SO) and their relationship with sex steroids in MLWH aged < 50.

METHODS

Prospective, cross-sectional, observational study on MLWH younger than 50 (median age 47.0 years). BC and BMD were evaluated with DXA. Two different definitions of sarcopenia were applied: appendicular lean mass/height2 (ALMI) < 7.26 kg/m2 or appendicular lean mass/body weight (ALM/W) < 28.27%. Low BMD was defined for Z-score < -2.0. Sarcopenia coupled with obesity identified SO. Serum total testosterone (T) and estradiol (E2) were measured by LC-MS/MS; free testosterone (cFT) was calculated by Vermeulen equation.

RESULTS

Sarcopenia was detected in 107 (34.9%) and 44 (14.3%) out of 307 MLWH according to ALMI and ALM/W, respectively. The prevalence of SO was similar by using both ALMI (11.4%) and ALM/W (12.4%). Sarcopenic and SO MLWH had lower total T and cFT in both the definition for sarcopenia. BMD was reduced in 43/307 (14.0%). Serum E2 < 18 pg/mL was an independent contributing factor for sarcopenia, SO, and low BMD.

CONCLUSIONS

T and E2 are important determinants of BC even in MLWH. This is among the first studies investigating the distribution of obesity phenotypes and the prevalence of SO among MLWH showing that SO is present in 11-12% of enrolled MLWH regardless of the definition used. However, deep differences emerged using two different diagnostic definitions.

Cold Therapy for Pain Control in Pediatric Appendectomy Patients: A Randomized Controlled Trial

PURPOSE

Topical ice has been shown to reduce pain scores and opioid use in adults with midline abdominal incisions. This study was designed to evaluate the efficacy of a cold therapy system in children following laparoscopic appendectomy.

METHODS

Patients 7 years and older who underwent laparoscopic appendectomy at our institution from December 2021-September 2022 were eligible. Patients were randomized to standard pain therapy (control) or standard plus cold therapy (treatment) utilizing a modified ice machine system with cool abdominal pad postoperatively. Pain scores on the first 3 postoperative days (PODs), postoperative narcotic consumption, and patient satisfaction were analyzed.

RESULTS

Fifty-eight patients were randomized, 29 to each group. Average survey response rate was 74% in control and 89% in treatment patients. There was no significant difference in median pain scores or narcotic use between groups. Cold therapy contributed to subjective pain improvement in 71%, 74%, and 50% of respondents on PODs 1, 2, and 3 respectively.

CONCLUSION

A majority of patients reported cold therapy to be a helpful adjunct in pain control after appendectomy, though it did not reduce postoperative pain scores or narcotic use in our cohort - likely due to this population's naturally expedient recovery and low baseline narcotic requirement.

TYPE OF STUDY

Randomized Controlled Trial.

LEVEL OF EVIDENCE

Level I.

Field output correction factors of small static field for IBA razor nanochamber

Purpose.The goal of this work is present results of field output factors (OF) using an IBA CC003 (Razor NanoChamber) and compare these results with PTW 60019 (MicroDiamond) and IBA Razor Diode. The experimental results for IBA CC003 were also compared with Monte Carlo (MC) Simulation, using Penelope and Ulysses programs. In addition, field output correction factors (kQclin,Qmsrfclin,fmsr) for IBA CC003 were derived with three different methods: (1) using PTW 60019 and IBA Razor as reference detectors; (2) comparison between MC and experimental measurements; and (3) using only MC.Material and Methods. The beam collimation included in this study were (1) square field size between 10 × 10 and 0.5 × 0.5 cm2defined by the MLC and jaws and (2) cones of different diameters. For IBA CC003 it was determined the polarity and ion collection efficiency correction factors in parallel and perpendicular orientation.Results.The results indicate (1) the variation of polarity effect with the field size is relevant for the determination of OF using IBA CC003, especially for parallel orientation; (2) there is no significant variation of the ion collection efficiency with the field size using IBA CC003 in parallel orientation; (3) OF differences between IBA CC003 and PTW 60019/IBA Razor, and experimental and MC results, increase with decreasing field size;ThekQclin,Qmsrfclin,fmsrresults indicate (1) using the first and second method,kQclin,Qmsrfclin,fmsrincrease with decreasing field size, which can be related with the influence of the volume effect and (2) using the third method,kQclin,Qmsrfclin,fmsrdecrease with decreasing field size, which can be explained by the perturbation effect.Conclusions. Our results demonstrate the need of applyingkQclin,Qmsrfclin,fmsrfor IBA CC003 forSclin≤1 cm, to compensate for volume averaging and perturbations effects.

Long-term trajectories of bone metabolism parameters and bone mineral density (BMD) in obese patients treated with metabolic surgery: a real-world, retrospective study

PURPOSE

Potential negative effects of metabolic surgery on skeletal integrity remain a concern, since long-term data of different surgical approaches are poor. This study aimed to describe changes in bone metabolism in subjects with obesity undergoing both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

METHODS

A single center, retrospective, observational clinical study on real-world data was performed enrolling subjects undergoing metabolic surgery.

RESULTS

123 subjects were enrolled (males 31: females 92; ages 48.2 ± 7.9 years). All patients were evaluated until 16.9 ± 8.1 months after surgery, while a small group was evaluated up to 4.5 years. All patients were treated after surgery with calcium and vitamin D integration. Both calcium and phosphate serum levels significantly increased after metabolic surgery and remained stable during follow-up. These trends did not differ between RYGB and SG (p = 0.245). Ca/P ratio decreased after surgery compared to baseline (p < 0.001) and this decrease remained among follow-up visits. While 24-h urinary calcium remained stable across all visits, 24-h urinary phosphate showed lower levels after surgery (p = 0.014), also according to surgery technique. Parathyroid hormone decreased (p < 0.001) and both vitamin D (p < 0.001) and C-terminal telopeptide of type I collagen (p = 0.001) increased after surgery.

CONCLUSION

We demonstrated that calcium and phosphorous metabolism shows slight modification even after several years since metabolic surgery, irrespective of calcium and vitamin D supplementation. This different set point is characterized by a phosphate serum levels increase, together with a persistent bone loss, suggesting that supplementation alone may not ensure the maintenance of bone health in these patients.

Novel unconventional radiotherapy techniques: Current status and future perspectives - Report from the 2nd international radiation oncology online seminar

•Improvement of therapeutic ratio by novel unconventional radiotherapy approaches.•Immunomodulation using high-dose spatially fractionated radiotherapy.•Boosting radiation anti-tumor effects by adding an immune-mediated cell killing.

Ketamine use for management of vaso-occlusive pain in pediatric sickle cell disease

BACKGROUND

Typical sickle cell disease (SCD) vaso-occlusive pain episode (VOE) management includes opioids, which are often inadequate and can be associated with significant side effects. Ketamine, a dissociative anesthetic, is a potentially effective adjunct to VOE management.

OBJECTIVES

This study aimed to characterize ketamine use for VOE management in pediatric SCD.

METHOD

This retrospective case series summarizes a single-center experience regarding the use of ketamine for inpatient management of pediatric VOE in 156 admissions from 2014 to 2020.

RESULTS

Continuous low-dose ketamine infusion was most commonly prescribed to adolescents and young adults as an adjunct to opioids (median starting dose 2.0 μg/kg/min; median maximum dose 3.0 μg/kg/min). Ketamine was started a median of 13.7 hours after admission. Median ketamine infusion duration was 3 days. In most encounters, ketamine infusion was discontinued prior to opioid patient-controlled analgesia (PCA) discontinuation. The majority of encounters (79.3%) had a reduction in either PCA dose, continuous opioid infusion, or both while receiving ketamine. Low-dose ketamine infusion was associated with side effects noted in 21.8% (n = 34) of encounters. The most common side effects included dizziness (5.6%), hallucinations (5.1%), dissociation (2.6%), and sedation (1.9%). There were no reports of ketamine withdrawal. Most patients who received ketamine went on to receive it again during a subsequent admission.

CONCLUSION

Further study is needed to determine the optimal timing of ketamine initiation and dosing. The variability of ketamine administration highlights the need for standardized protocols for ketamine use in VOE management.

P23 TIMING OF EJECTION FRACTION REASSESSMENT AFTER SACUBITRIL–VALSARTAN INITIATION FOR INDICATION TO DEFIBRILLATOR IMPLANTATION. A SINGLE CENTER EXPERIENCE

Background

Sacubitril/Valsartan (SV) has been validated for heart failure (HF) with reduced ejection fraction (EF) treatment. SV is effective on hard end–points as well as symptoms and heart remodeling. Present guidelines reccomend at least 3 month of optimized medical therapy (OMT). However, the best timing of EF assessment after SV initiation in order to proceed with defibrillator (ICD) implantation, is still unknown.

Purpose

Evaluate timing of improvement of EF after SV initiation in patients (pts) with systolic HF, candidates to primary prevention ICD implantation.

Methods

From 1 of february 2018, we evaluated retrospectively clinical and echocardiographic data of all consecutive pts with EF &lt; 35% treated with SV and candidates to primary prevention ICD implantation. We evaluated clinical and echo follow up (Fup). Results have been analyzed with paired T–test.

Results

The study involved 95 pts (mean age 67±10 years, 70% male, ischaemic etiology 48%). Mean EF at enrollment was 30 ± 5% (ED vol 90 ±23 ml/m2; ES vol 62 ± 19 ml/m2, severe MR 23%) and NYHA III–IV 50%. In 58% pts reached the target dose of SV (97/103 mg bid). After a mean Fup of 6 months, mean EF of the study population increased to 37±7% (ED vol 80±19 ml/m2, ES vol 51±17 ml/m2, severe MR 5%, p &lt; 0.001), and NYHA III–IV decreased to 8% (p = 0.01). Interestingly, thirty–one pts (32%) had their first Fup within 3 months and showed already an improvement [meanEF 28±5% to 35±6%; ΔEF 7±6%; NYHA III–IV 10 %]. Moreover, 49 pts (51%) had last Fup echo after 1 year (mean 13±6 months) and showed a further EF improvement (meanEF 41±8%; ΔEF 12±9%; p &lt; 0.001).Sixteen pt (16%) underwent ICD (62%) or CRT–D (38%) implantation after 3±2 months of treatment and excluded from further FUP analysis. More favorable effects of treatment with SV were more evident in patient with non–ischaemic etiology of heart failure.

Conclusions

After SV initiation in systolic HF, favourable heart remodeling is clearly evident at 6 months FUP, but could be already observed after 3 months . These findings need to be validated from larger trials but suggest that the best timing of EF reassessment to decide for primary prevention ICD is likely between 3 and 6 months after SV initiation. However decision must be taken following close and individualized FUP for every patient, based on clinical characteristics and response to OMT.

The impact of modern radiotherapy on long-term cardiac sequelae in breast cancer survivor: a focus on deep inspiration breath-hold (DIBH) technique

INTRODUCTION

One of the most feared side effects of radiotherapy (RT) in the setting of breast cancer (BC) patients is cardiac toxicity. This side effect can jeopardize the quality of life (QoL) of long-term survivors. The impact of modern techniques of RT such as deep inspiration breath hold (DIBH) have dramatically changed this setting. We report and discuss the results of the literature overview of this paper.

MATERIALS AND METHODS

Literature references were obtained with a PubMed query, hand searching, and clinicaltrials.gov.

RESULTS

We reported and discussed the toxicity of RT and the improvements due to the modern techniques in the setting of BC patients.

CONCLUSIONS

BC patients often have a long life expectancy, thus the RT should aim at limiting toxicities and at the same time maintaining the same high cure rates. Further studies are needed to evaluate the risk-benefit ratio to identify patients at higher risk and to tailor the treatment choices.

Timing of ejection fraction reassessment after sacubitril-valsartan initiation for indication to defibrillator implantation. A single center experience

Background

Sacubitril/Valsartan (SV) has recently been validated in the therapy of heart failure (HF) with reduced ejection fraction (EF). SV is effective on symptoms and heart remodeling. At the moment the best timing to EF assessment after SV initiation in order to proceed with defibrillator (ICD) implantation, it's unknown.

Purpose

Evaluate the timing of improvement of EF after SV initiation in patients (pts) with systolic HF, candidates to primary prevention ICD implantation.

Methods

We enrolled all consecutive pts candidates to primary prevention ICD implantation that underwent SV initiation from February 2018. We evaluated clinical and echo follow up (Fup). Results have been analyzed with paired T-test).

Results

The study involved 61 pts (mean age 67±10 years, 71% male, ischemic cardiopathy 44%, mean time from diagnosis 31 months) with mean EF at enrollment 30±5% (ED vol 94 ml/m2, ES vol 64 ml/m2, severe MR 21%) and mean NYHA 3±0.6. After a mean Fup of 6 months mean EF increased to 37±7% (ED vol 80 ml/m2, ES vol 51 ml/m2, severe MR 8%, p&lt;0.004), NYHA decreased to 2±0.6 (p&lt;0.04). In 69% pts SV dosage reached 97/103 mg bid. 28 pts (45%) had first Fup at 3 months and showed already mean EF 34±6% and mean NYHA 1.6±0.6 (p&lt;0.04). 26 pts (43%) had last Fup echo after 1 year (mean 17±10 months) and showed further EF little improvement (38.3±8%, p 0.05).

Conclusions

After SV initiation in systolic HF, heart remodeling is already evident at 3 months Fup and better appreciable at 6 months Fup. Little non significant further EF improvement could be seen later. In our study best timing to decide for primary prevention ICD is likely between 3 and 6 months after SV initiation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

BLITZ-HF study: a nationwide initiative to assess and improve guidelines recommendations adherence in cardiology centers managing patients with acute and chronic heart failure

Background

Physicians adherence to heart failure (HF) guidelines is generally sub-optimal with consequent negative prognostic implications. Strategies to improve adherence to guideline recommendations are strongly needed.

Aims

To assess and improve adherence of Italian cardiology sites to guidelines recommendations on performance indicators in patients with acute (AHF) and chronic heart failure (CHF).

Methods

BLITZ-HF was a prospective study based on a web based recording system used during two enrollment periods (phase 1 and 3), interspersed by face-to-face macro-regional benchmark analysis and educational meetings (phase 2). Both management (creatinine and echocardiographic evaluations or discharge follow-up planning) and treatment (according to ejection fraction categories, focusing on guidelines directed medical treatments - GDMTs) performance indicators were considered for patients in both settings.

Results

Overall, 7218 patients with acute and chronic HF were enrolled at 106 sites. During the enrollment phases, 3920 and 3298 patients were included respectively, 84% with CHF and 16% with AHF in phase 1, 74% with CHF and 26% with AHF in phase 3. In Figure 1 we report adherence to management and treatment indicators in the two enrollment phases. Among AHF patients improvement was obtained in two of seven indicators. A significant rise in echocardiographic evaluation was observed, while discharge schedule of a cardiology ambulatory evaluation within four weeks was overall poor (less than 50%) and did not improve in the 3 phase. Overall GDMTs prescription rate in HFrEF was good and we observed a nominal increase in betablockers prescription rate in Phase 3. Among CHF patients with HFpEF and HFmrEF we observed a performance increase in two of three indicators: creatinine end echocardiographic evaluations, while oral anticoagulation in atrial fibrillation remained stably high. Performance measures in CHF HFrEF patients improved in six of nine indicators although significantly only in two. Prescription rate of GDMTs was good already in phase 1 and a significant increase in ACE-I/ARB or ARNI prescription was reported, with a nominal increase in the use of one of these three drugs in combination with MRAs and a BB.

Conclusions

A structured multifaceted educational intervention can improve adherence to HF guidelines on several indicators in a context of an already elevated level of adherence to guideline recommendations. Extension of this approach to other non-cardiology health professional settings, in which patients with HF are generally managed, should be considered.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

Practical management of epidermolysis bullosa: consensus clinical position statement from the European Reference Network for Rare Skin Diseases

Inherited epidermolysis bullosa (EB) comprises rare disorders that manifest with fragility and blistering of the skin and mucous membranes, with variable clinical severity. Management of EB is challenging due to disease rarity and complexity, the wide range of extracutaneous manifestations and a profound impact on daily life for the patient and family members. Although reference centres providing multidisciplinary care for EB exist in each European country, it is common for healthcare professionals that are not specialized in this rare disorder to treat EB patients. Here, experts of the European Reference Network for Rare and Undiagnosed Skin Diseases (ERN-Skin, https://ern-skin.eu) propose practical recommendations for the diagnosis and management of the commonest clinical issues, skin blisters and wounds, oral manifestations, pain and itch.

A systematic review of ketamine for the management of vaso-occlusive pain in sickle cell disease

Vaso-occlusive episodes (VOEs) are a common complication of sickle cell disease (SCD) and a significant cause of morbidity. Managing VOE pain can be difficult and complex. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been used to manage VOE pain. This systematic literature review synthesizes research published from 2010 to 2020 on the use of ketamine infusion to decrease VOE pain. The review demonstrates that ketamine, a safe and effective treatment for VOE pain, could be considered more widely. However, the significant variability among published clinical studies with regard to dosing, timing of initiation, duration of infusion, and timing of discontinuation highlights the need for standardized ketamine infusion protocols for the management of VOE pain. We conclude with a brief discussion of key components of a potential standardized protocol supported by the literature reviewed as well as areas for future investigation.

Contributi scientifici in memoria di Antonio Fusco

Come si leggerà nell'Introduzione della sezione propriamente scientifica del Volume, il presente testo nasce dalla volontà e, soprattutto, dall'esigenza culturale di omaggiare il fu Prof. Antonio Fusco. Un debito scientifico ed umano che trova il suo locus naturale in questa prima parte del testo stesso, cui farà poi seguito la parte propriamente scientifica. In siffatta parentesi dovuta per le ragioni appena menzionate, il lettore, l'amico o l'allievo dell'opera del Prof. Fusco potranno trovare un suo sintetico Curriculum Vitae, correlato da una specifica ed accurata prosa, svolta dal già Magnifico Rettore Carlo Cipolli; il quale, oltre che evidenziare, ricordando, i meriti del collega oramai scomparso, aggiunge alsuo scritto un elemento che sarebbe imprescindibile a non trasformare lo stesso in una mera sequenza di parole: l'amicizia e l'affetto per un amico che, oramai, non c'è più. A fine lettura, evidente risuonerà il fatto che la vita di ognuno, se mossa dalla passione per ciò per cui si è predisposti cognitivamente e psicologicamente, può essere ricca di riconoscimenti, riconoscenze e soddisfazioni che, lungi dal divenire un cuscino di allori su cui adagiarsi, per una mente creativa come quella del Prof. Fusco hanno funto solo da motivazioni ad agire instancabilmente guardando sempre al futuro. Il lavoro di una vita che, materialmente, è sancito da un supporto poco più di cm 25x15: una targa. Una materialità evidente che, con grande commozione e riconoscenza, è stata affissa il 25 ottobre 2019 sull'aula fronte l'Aula Magna del Campus "La Folcara", a testimonianza che quello spirito creativo in continua evoluzione non si ferma; non si arresta neppure con la fine biologica di chi lo ha "posseduto". Rimangono le opere ed il pensiero del Prof. Fusco e restano gli affetti. A tal proposito, il lettore troverà una breve e sentita sezione su Testimonianze; coloro i quali hanno avuto modo, nell'arco della vita accademica ed umana, personale, di Fusco di conoscerlo. Ecco, allora, che i ricordi saranno i veri protagonisti di questa parentesi. Dopo di ciò, prima dei contributi prettamente scientifici dei lavori, tenutisi in occasione del Convegno Internazionale Psicologia, Arte, Letteratura. Antiche e Nuove Tendenze, seguiranno i saluti delle autorità che in quei due giorni si sono succedute a rappresentare non solo l'istituzione affiliata, ma anche la relazione di stima e di affetto che le legava al compianto Professore. Si passerà, infine, al volume tradizionalmente inteso.

Diversity of Secondary Metabolism in Aspergillus nidulans Clinical Isolates

The filamentous fungus Aspergillus nidulans has been a primary workhorse used to understand fungal genetics. Much of this work has focused on elucidating the genetics of biosynthetic gene clusters (BGCs) and the secondary metabolites (SMs) they produce. SMs are both niche defining in fungi and of great economic importance to humans. Despite the focus on A. nidulans, very little is known about the natural diversity in secondary metabolism within this species. We determined the BGC content and looked for evolutionary patterns in BGCs from whole-genome sequences of two clinical isolates and the A4 reference genome of A. nidulans Differences in BGC content were used to explain SM profiles determined using liquid chromatography-high-resolution mass spectrometry. We found that in addition to genetic variation of BGCs contained by all isolates, nine BGCs varied by presence/absence. We discovered the viridicatumtoxin BGC in A. nidulans and suggest that this BGC has undergone a horizontal gene transfer from the Aspergillus section Nigri lineage into Penicillium sometime after the sections Nigri and Nidulantes diverged. We identified the production of viridicatumtoxin and several other compounds previously not known to be produced by A. nidulans One isolate showed a lack of sterigmatocystin production even though it contained an apparently intact sterigmatocystin BGC, raising questions about other genes and processes known to regulate this BGC. Altogether, our work uncovers a large degree of intraspecies diversity in BGC and SM production in this genetic model species and offers new avenues to understand the evolution and regulation of secondary metabolism.IMPORTANCE Much of what we know about the genetics underlying secondary metabolite (SM) production and the function of SMs in the model fungus Aspergillus nidulans comes from a single reference genome. A growing body of research indicates the importance of biosynthetic gene cluster (BGC) and SM diversity within a species. However, there is no information about the natural diversity of secondary metabolism in A. nidulans We discovered six novel clusters that contribute to the considerable variation in both BGC content and SM production within A. nidulans We characterize a diverse set of mutations and emphasize how findings of single nucleotide polymorphisms (SNPs), deletions, and differences in evolutionary history encompass much of the variation observed in nonmodel systems. Our results emphasize that A. nidulans may also be a strong model to use within-species diversity to elucidate regulatory cross talk, fungal ecology, and drug discovery systems.

Concomitant medullary thyroid carcinoma with paraganglioma-like pattern and papillary thyroid carcinoma

SUMMARY

A 74-year-old man was referred to the Endocrinology Unit because of multinodular goiter. The dominant nodule (1.7 × 1.9 × 2.4 cm), at the medium-superior third of the left lobe, was inhomogeneously hypoechoic, with irregular margins, macrocalcifications and intranodular vascularization. Fine-needle aspiration biopsy (FNAB) was performed. The cytological diagnosis was TIR 2, benign, according to the 2013 Italian thyroid cytology classification system. Moderately high serum calcitonin (s-Ct) (61.5 pg/mL, n.r. 0-7.5) and normal CEA were detected. The Ct level in FNAB wash-out fluid (Ct-FNAB) was 1450 pg/mL. Based on s-Ct and Ct-FNAB levels, patient underwent total thyroidectomy. Macroscopically, a dominant circumscribed nodule of 2 ecm was described; the histological and immunohistochemical features identified medullary thyroid carcinoma (MTC) with paraganglioma (PG)-like pattern positive for Ct, CEA and chromogranin and negative for S-100 sustentacular cells (SC). Moreover, papillary carcinoma of 3 mm in the right lobe was also associated. No areas of hyperaccumulation of the tracer were documented at Ga68 PET/CT. No RET-proto-oncogene mutations were found. Post-surgery s-Ct levels were within normal range (4 pg/mL). Two years after thyroidectomy, the patient is still disease-free. We reported a case of sporadic and rare variant of MTC: this is the ninth described case of PG-like MTC. In this case, cytologically benign, the clinical suspicion arose from high Ct values at FNAB wash-out fluid. Even if clinical behavior of this variant seems indolent, additional studies are necessary to understand prognoses and predictive factors.

LEARNING POINTS

Several unusual histological variants of medullary thyroid carcinoma (MTC) have been described such as spindle cell, giant cell, clear cell, melanotic, squamous, angiosarcoma-like variants; even rarer is the paraganglioma (PG)-like pattern. We here describe a case of medullary PG-like thyroid carcinoma in a 74-year-old man. This is a rare histological variant of MTC hardly diagnosed by cytology, since immunohistochemical investigations are necessary. Measurement of calcitonin both in serum and in wash-out fluid from fine-needle aspiration could be an additional tool for an early and non-invasive identification of these variants.

P4613Long-term impact of postnatal nutritional programming on cardiac sensitivity to ischemia-reperfusion injury in vivo and on cardio-protective pathways in mice

Introduction

Nutritional disturbances during the postnatal period may be responsible for a predisposition, or “programming”, to increased cardio-metabolic risk and to a progressive alteration of left ventricular contractility in adulthood. This nutritional perinatal programming may also lead to an alteration of cellular pathways involved in cardiac protection, such as the specific RISK and SAFE pathways, highlighted during pre- and post-ischemic conditioning or those of sirtuins (SIRT), histone deacetylases involved in the regulation of essential biological process.

Purpose

Our aim was to evaluate in mice the impact of postnatal overfeeding (PNOF) on cardiac sensitivity to ischemia-reperfusion (I-R) injury in vivo and on the myocardial expression of genes involved in heart protection against ischemia.

Methods

PNOF was induced by the reduction of litter size of C57/BL6 mice immediately after birth: normally-fed group (NF) was composed of 9 male pups/mother and overfed group (OF) of 3 pups/mother. In vivo ischemia-reperfusion injury was induced by the ligation of the anterior interventricular artery for 45 minutes followed by 24 h of reperfusion in hearts from 6-months aged mice. The gene expressions of proteins of interest composing the cardioprotective pathways (RISK pathway: Akt, ERK; SAFE pathway: JAK/STAT3; Sirtuins: SIRT1) were measured by RT-qPCR in mice aged 4 and 6 months.

Results

PNOF induced in OF group an early and permanent increase in body weight (+23%, p<0.01, n=11) and a significant increase of infarct size (+32%, p<0.05, n=11) at 6 months. Hearts OF mice aged 4 months showed a decreased expression of cardioprotective pathways, represented by a reduction in the gene expression of ERK1, Akt, PI3K, STAT3 and SIRT1. At 6 months, the expression of cardioprotective pathways was also reduced in OF group, with the diminution of the gene expression of STAT3, Akt and Erk1.

Conclusion

Nutritional programming through short-term PNOF induced a long-lasting decrease in the expression of signaling pathways involved in cardiac cellular protection, which could explain why 6-months old mice show increased susceptibility to myocardial I-R injury in vivo. The mechanism of these alterations needs further exploration, but could involve alterations in cardiomyocyte's balance between apoptotic and regenerative pathways, and epigenetic modifications.

Acknowledgement/Funding

French Fundation

Glycaemic variability is associated with severity of coronary artery disease in patients with poorly controlled type 2 diabetes and acute myocardial infarction

BACKGROUND

In patients with type 2 diabetes (T2D), glycaemic variability (GV), another component of glycaemic abnormalities, is a novel potentially aggravating factor for coronary artery disease (CAD).

OBJECTIVES

The aim of our study was to identify interactions between GV and severity of CAD in diabetes patients admitted for acute myocardial infarction (AMI).

METHODS

All patients with T2D admitted to our university hospital for AMI from March 2015 to February 2017 who received intravenous (IV) insulin therapy and underwent coronary angiography were included. GV was assessed by mean amplitude of blood glucose excursion (MAGE) values taken within 2 days of admission. Patients with higher GV (highest MAGE tertile) were compared with those with lower GV (first and second MAGE tertiles).

RESULTS

A total of 204 patients were included: median age was 72 (61-81) years; 32% were female; HbA_1c was 7.3% (6.4-8.2%); diabetes duration was 10 (2-17.5) years; and MAGE value was 0.65 (0.43-0.92) g/L. Compared with those with lower GV, patients with the highest GV were more often women, treated with previous insulin, and had higher blood glucose and HbA_1c levels. In addition, patients with elevated GV had significantly higher SYNTAX scores: 17 (10-28) vs. 12 (6-22) (P = 0.009). Indeed, SYNTAX scores (OR: 1.05, 95% CI: 1.02-1.08; P = 0.001) remained independently associated with high GV beyond HbA_1c levels (OR: 1.51, 95% CI: 1.2-1.89; P <  0.001).

CONCLUSION

In AMI patients with poorly controlled diabetes, GV is associated with CAD severity beyond chronic hyperglycaemia. Although no causality can be determined from our observational study, the results suggest that, in AMI, early evaluation of GV might contribute to the identification of those diabetes patients at high risk, and serve as a therapeutic target for both primary and secondary prevention.

C-Myc Deregulation is Involved in Melphalan Resistance of Multiple Myeloma: Role of PDGF-BB

Oncogenes are important regulators of cancer growth and progression and their action may be modulated by proteins of the growth factor family, such as angiogenic cytokines, known to be strongly involved in neoplastic evolution. Reciprocal interactions between oncogenes and angiogenic modulators may represent, in haematological neoplasms, including multiple myeloma (MM), a possible mechanism of drug resistance. The aim of this work is to investigate in vitro and in vivo whether or not c-myc deregulation is involved in the melphalan resistance elicited by myeloma patients and consequently to clarify the role of the angiogenic factor PDGF-BB in modulating c-myc protein expression. Fifty-one MM patients on chemotherapy with melphalan were analyzed for structural alterations of the c-myc gene, c-Myc protein expression, as well as for serum PDGF-BB release. For the in vitro study, two M14-derived established cell clones, differing for the c-Myc protein expression (c-Myc low -expressing or constitutively expressing clones) were used. Our results show that PDGF-BB is able to up-regulate Myc expression and reduce melphalan sensitivity of tumor cell clones, constitutively expressing c-myc gene product. In addition, down-regulation of c-Myc protein induces the expression of PDGF-β receptor molecules and reduces PDGF-BB release. In agreement with these results, in vivo data show that melphalan-resistant MM patients present overexpressed c-Myc protein and higher serum PDGF-β receptor levels compared to minor responding patients.

Cyclophosphamide and Iphosphamide against Lewis Lung Carcinoma: Evaluation of Toxic and Therapeutic Effects

In the present report, investigations have been carried out to evaluate toxic and therapeutic effects of cyclophosphamide vs its isomer iphosphamide. Cytostatic action of the 2 drugs was assayed on the murine Lewis lung carcinoma (3LL). It has been observed that iphosphamide is less toxic as compared to cyclophosphamide [Formula: see text]; on the other hand, to reach the same therapeutic effectiveness on 3LL, an iphosphamide dose 1.6 - 2 times higher than that of its parent compound is necessary.